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Hay Jr, Robert NEW YORK STATE DEPARTMENT OF HEALTH ' y Vital Records Section Burial - Transit Permit Name First Middle Last J r, Sex Robes a- CrncsIt1 Hwy M Date of Death Age ! If Veteran of U.S. Armed Forces. 01 ( So a 2a►.o $1.9 i War or Dates NI A , 44 Place of Death Hospital, Institution or City own r Village Fo r i- Ed o► Street Address Fork H�xisar a�t #t S S4.enekS' 141— Manner o Death Natural Cause ElAccident fl Homicide 0 Suicide Undetermined 0 Pending ill Circumstances Investigation Medical Certifier Name Title l 'crnaird v Vi hha j u In)) Address 3 )'i Broad wctv 'Rid- Ed weird, A/1 I nag lit Death Certificate Filed District Numb Registe /Number «: Ci , Tow r Village Fr A- Ed Wgrcd 55 � Date Cemetery col Crematory., El Burial al 01 f A.01 to ?ink Vle.,`1\ ire 'a-t-o✓y Address / ;': Cremation Q�ey‘Slry otl f Ny 12�aii Date 1 1 ( Place Removed • - 0C Removal ; and/or Held and/or Address 0 r Hold 0 Date Point of NQ Transportation , Shipment 5 by Common Destination . Carrier [�Disinterment Date I Cemetery Address I 1 Reinterment 1 Date ,Cemetery Address ><- Permit Issued to ) Registration Number ; Name of Funeral Home __ _ /4-Kt: k.:•� v , . j74N ©/)c3Q Address i/ r o 6 `` Ci- 5u .01-a or Ay l LP-CI If << Name of Funeral FYm Making Disposition or to Whom ; I - Remains are Shipped, If Other than Above `� Address Permission is hereby granted to dispose of the hulgrei ins I'I,essc. c i ab indicated. Date Issued I-I( , Registrar of Vital Statisti.J U`�,C�C.�V (s".' ture� ....) 5165 /O1,1J'7& , ef-8,t- 610 jaAci( District Number Place I certify that the remains of the decedent identified above were disposed of,,in accordance with this permit on: W Date of Disposition 81311/6 Place of Disposition .�n&th _ Gw va1"7v W (address) -- Cl) IX (section) (lot number) (grave number) GName of Sexton or Person-in Charge of Premises • /AiTut - .lC.q" (please print) U ? Signaturea • Title rope - (over) DOH-1555 (9/98)